Healthcare Provider Details

I. General information

NPI: 1992943922
Provider Name (Legal Business Name): ANA E GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12730 HAWTHORNE BLVD STE D
HAWTHORNE CA
90250-3919
US

IV. Provider business mailing address

12730 HAWTHORNE BLVD STE D
HAWTHORNE CA
90250-3919
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-4000
  • Fax: 310-644-3232
Mailing address:
  • Phone: 310-644-4000
  • Fax: 310-644-3232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number4490725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: